What is the best approach to obtaining a patient history in emergency medicine?

Best Approach to Patient History in Emergency Medicine

The best approach to obtaining a patient history in emergency medicine is through a focused medical assessment directed by the patient's presenting complaint, rather than routine comprehensive testing for all patients. 1

Core Components of Emergency Medical History

Initial Assessment

• Obtain a focused history regarding the timing of symptom onset (or the time the patient was last normal) 1
• Document medical history, medication, and drug use information 1
• Perform a baseline severity score as part of initial evaluation 1
• Rapidly identify high-risk patients who may require immediate intervention 1

Key Documentation Elements

• Chief complaint and duration of symptoms 2
• Pertinent positive and negative findings 2
• Relevant past medical history 2
• Medications and allergies that impact treatment decisions 2

Risk-Based Approach to History Taking

High-Risk Patient Groups Requiring More Detailed Assessment

• Elderly patients 1
• Patients with substance abuse 1
• Patients without prior psychiatric history (when presenting with psychiatric complaints) 1
• Patients with preexisting or new medical complaints 1
• Patients of lower socioeconomic status 1

Adapting History Taking to Patient Condition

• For alert, cooperative patients: complete focused assessment based on presenting complaint 1
• For patients with altered mental status: obtain collateral history from family, EMS, or witnesses 1
• For critically ill patients: prioritize immediate life-threatening issues while gathering essential history in parallel 1

Communication Techniques

• Provide advance notice to ED of potential critical patients to initiate pathways and alert consulting services 1
• Use active listening and empathetic communication 3
• Employ cultural sensitivity when gathering information 3
• Engage patients in conversation about their health issues to facilitate participation and autonomy 3

Documentation Best Practices

• Clearly articulate thought processes, including differential diagnoses considered 2
• Document rationale for pursuing specific diagnostic tests 2
• Record interpretation of diagnostic results and how they influenced clinical decision making 2
• Use standardized templates to improve documentation completeness, but avoid over-reliance on auto-populated content 2

Avoiding Common Pitfalls

Information Overload

• Focus on clinically relevant information rather than collecting excessive data 4
• Prioritize information gathering based on acuity and presenting complaint 4
• Recognize that information overload can lead to guideline fatigue, stress, and impaired decision making 4

Inappropriate Testing

• Avoid routine laboratory testing for all patients, as it has very low yield 1
• For psychiatric patients with normal vital signs and noncontributory history/physical exam, routine laboratory testing is unnecessary 1
• Direct diagnostic evaluation by the history and physical examination findings 1

Documentation Errors

• Avoid using "do not use" abbreviations 1
• Ensure legibility in written documentation 1
• Incorporate laboratory, radiologic, and allied health testing results appropriately 1

Technology Integration

• Consider using electronic documentation systems with emergency physician input 1, 2
• Utilize decision support tools that can facilitate shared decision-making 2
• Be aware that older patients may have less confidence with digital technology for history taking 5

By following this structured approach to obtaining patient history in emergency medicine, clinicians can efficiently gather the most relevant information while avoiding unnecessary testing and information overload, ultimately improving patient care and outcomes.